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'' t11E try e BARIYSIABIE, * '... . TOWN Permit 9 MASS. � 1639. 'OTFD •�a�0 . Permit Number: Application Ref: 201501660 20150775 Issue Date: 04/17/15 Applicant: RIVERA, MAURO O & AIDA Proposed Use: Accessory Structure ; Permit Type: SHEDS 200 SQ FT & UNDER Permit Fee $ 35.00 Location 617 STRAWBERRY HILL ROAD Map Parcel 249018 Town CENTERVILLE Zoning District RD-1 Contractor PROPERTY OWNER Remarks 12X12 SHED Owner: RIVERA, MAURO O & AIDA Address: 34 STRAWBERRY HILL RD CENTERVILLE, MA 02632 Issued By: JL ", POST THIS.CARD_SO4 THAT IS,VISIBLE FROM TH T Town of Barnstable �TME'gti Regulatory Services Richard V.Scali,Director 9 MASS. Building Division 16.39. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable-ma.us Office: 508-862-403.8 Fax: 508-790-6230 PER HT# 1:�© �S ® � FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less Location of shed(address) Village A dr �IUERA S08)292-2 55� Property owner's name Telephone number /P-,-y V Size of Shed Map/Parcel# ;�I Signature Date M Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) r Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMNIISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN I Q-forms-shedreg REV:040914 Map Page 1 of 1 Town of Barnstable Geographic Information System New Sear Parcel Viewer Custom Map Abuttere Map Sue ® ® Zoom Out In y Turn map layers on/off by ]PG selecting check boxes below 140058' r.Town Boundaries %645 Er. �'. Road Names 249105 r' Voter Precincts 13 Multiple Address House Numbers rs�y: F. Map&Parcel Numbers r Parcels FEMA Flood Zones 249019 Effective July 16,2014 _ VE-Velocity Zone I{ AE-100 year Flood AO-100 year flood t 0.2%Annual Chance Flood Open Water 249018 " .0817� r Neighboring Towns _ 249007 N 128 Water 7' Y Streams d Jetties 149028 Cl Edge of Water 24900e .._ r Marsh 0114 240020 962 " 249017 8. p 001 Feet (- Drainage bitch es 411 - - F. Water Bodies Set Scale 1"=48 .1 I Aerial Photos ;� I MAP DISCLAIMER copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableNiA V1.2.5494 [Production] http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=249... 4/1/2015 Av , 1` v l. �I L� i i f I Y j i � ' • • 1 � �� ` Parcel Lookup Page 1 of 1 4i� �y�� .� �,�" t• .`� ,sue_ .. _ - � " "� C� Mr} �` i!}1:�� ' �`aw- art•. _ A. .� Q r} JGJ Logged In As: Parcel Lookup Monday,April 22 2013 Road Lookup Condo Lookup Multiple Address Lookup Reports Search Options L Search By Owner �• Owner Name RIVERA Search, <Prev Next> Page 1 of 1 Rows/Page: 10 1 71 Parcel Location Owner Village Map 289-141 15 STERLING ROAD RIVERA,AIDA HY 289141 291-014 385 MITCHELL'S WAY RIVERA,AIDA G& MAURO HY 291014 291-016 458 PITCHER'S WAY RIVERA,ALPHONSO& DIANA HY 291016 252-085 943 PHINNEY'S LANE RIVERA, GEOVANY& MARIA N HY 252085 250-080 295 OLD STRAWBERRY HILL ROAD RIVERA, LUIS H HY 250080 249-018 617 STRAWBERRY HILL ROAD RIVERA, MAURO 0&AIDA CEN 249018 246-070 34 STRAWBERRY HILL ROAD RIVERA, MAURO 0&AIDA G CEN 246070 292-095 11 GENERAL PATTON DRIVE RIVERA, SUYAPA C I HY 1292095 http://issgl2/intranet/propdata/lookup.aspx 4/22/2013 Town of.Barnstable oFIME, Regulatory Services B �. u��. P`' o Thomas F. Geiler,Director � r Public Health Division BARNSTABLE, 9 MASS. Thomas McKean, Director cb 3G39. ,00 - 200 200 Mairi-Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 3, 2009 Mauro Rivera 34 Strawberry Hill Road Centerville, MA 02632 As of October 1, 2006.a new rental registration ordinance was put into affect requiring all property owners of rental units to register- ei'r rental units with the Town of Barnstable Health Division. According to our records, you own the.rental property at-617 Strawberry Hill Road, Centerville Enclo d'is an application.: Please use. a separate application for each rental unit you own. Should you�need more applications, they are available online at w ww.town.barn.stable.n�a.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration.information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2009 fees included. This must be-completed witja n.4(14) fourteen days of your receipt of this letter: Failure to comply with this ordinance will result in'the issuance of a non-criminal-ticket citation in the amount..of$100. Each day ofnon-compliance is considered a separate offense. Should you.have.any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. Timothy B. O'JConneil, R.S.. Health Inspector Health Division Direct#508-862-4646 t Barnstable Assessing Search Results Page 1 of 2 Home:Departments:Assessors Division:Property Assessment Search Results New Search ; New Interactive Maps>> Owner: 2009 Assessed Values: RIVERA,MAURO O&AIDA 617 STRAWBERRY HILL ROAD Appraised Value Assessed Value Map/Parcel/Parcel Extension Building Value: $136,000 $136,000 249 /018/ Extra Features: $3,300 $3,300 Outbuildings: $0 - $0 Mailing Address Land Value: $162,600 $162,600 RIVERA,MAURO O&AIDA Totals $301,900 $301,900 34 STRAWBERRY HILL RD CENTERVILLE,MA.02632 2009 REAL ESTATE Tax Information: Tax Rates:(per$1,000 of valuation) Community Preservation Act Tax $62.49 Fire District Rates Town Residential Barnstable FD-All Classes $2.37 $6.90 C.O.M.M.-All Classes $1.08 Town Commercial C.O.M.M.FD Tax(Residential) $326.05 Cotuit FD-All Classes $1.43 $6.12 Hyannis-Residential $1.78 Town Tax(Residential) $2,083.11 Hyannis-Commercial $2.77 W Barnstable-All Classes $2.11 Community Preservation Act 3%of Town Tax Total: $2,471.65 Construction Details Building Property Sketch & ASBUILT Cards Building value $136,000 Interior Floors Hardwood Property Sketch Legend Style Ranch Interior Walls Drywall Model Residential Heat Fuel Gas Grade Average Heat Type Hot WaterrK Stories 1 Story AC Type None a ` Exterior Walls Wood Shingle Bedrooms 3Bedrooms fi "' ' Roof Structure Gable/Hip Bathrooms 1 Full+1H Roof Cover Asph/F GIs/Cmp living area 1512 Replacement Cost $159972 Year Built. 1970 Depreciation 15 Total Rooms 5 Rooms Land CODE 1010 Lot Size(Acres) 0.51 AS Built Cards:1 Appraised Value $162,600 gwzt .2,View Interactive Maps >> Assessed Value $162,600 r Sales History: http://www.town.bamstable.ma.us/assessing/2009/displayparcelO9map.asp?mappar=249018 1/27/2010 Barnstable Assessing Search Results Page 2 of 2 Owner: Sale Date Book/Page: Sale Price: HOBAN,KAREN M TR Oct 25 2002 12:OOAM 15803/093 $1 ;' IVERA,MAURO 0&AIDA Oct 25 2002 12:OOAM 15803/095 $235,000 HOBAN,KAREN M TR Mar 8 2002 12:OOAM 14906/111 $160,000 SARACOL,INC Mar 8 2002 12:OOAM 149061 112 $100 BORGOS,PEDRO&VIVIAN R Aug 29 1997 12:OOAM 10925/177 $92,500 SCHIANO,ANTONIO&BARROS,V Apr 15 1992 12:OOAM 7996/297 $1 SCHIANO,ANTONIO 3217/024 $0 Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value FPLt Fireplace 1 $2,600 $2,600 FPO Ext FP Opening 1 $700 $700 Property Sketch Legend BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRIN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/assessing/2009/displayparcelO9map.asp?mappar=249018 1/27/2010 Assessors map and lot number .......... THE T��y Sewage Permit number /W ° House number ....f,!. /...................................................... WITH E 6 9�0 16& T„{. \0� ENVIRONMENTAL CODE r TOWN OF BARNSTABLr-FJI-ATiONs BURPING INSPECTOR APPLICATION FOR PERMIT TO (44VS Gt /r�-PuJ' V TYPE OF CONSTRUCTION ...... �L7,C J3......................(,L n - 14 pmis --- . w1.. ...........Iz...........19.201 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according t the following inform tion: g Location ..... .. ProposedUse ............................. ...�?- . ....... ........................................ ............................................................. 17 Zoning District ............... ......:1. ..............................................Fire District ..........:. Name of Owner ...K.. ... . ...................Address .... y ® �Srt....P7iTv ............................ ,,/ /J Name of Builder ....owml[. fidg.-e,��` ....... .5 J �'i � S.�!1.�.. '......... .......Address .... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms .................. .... .........................................Foundation .............................................................................. Exterior ................................ .. ............. .. .................Roofipg .................................................................................... Floors ...... .�.� ri4p Heating PlumbinQ�. Fireplace ..................................................................................Approximate Cost . .. /� oQ ................. ......... . .... ..... Definitive Plan Approved by Planning Board ---------------_---------------19--------. Area 1. .. . ........ .........`�.... Diagram of Lot and Building with Dimensions Fee ......................... ®� SUBJECT TO APPROVAL OF BOARD OF HEALTH � - I,7J(!(. Saw (sec 11u p I a c e- a .e)(I iwc mIgLl /gcr 1AIK4 A4am r f2-X/C otcl pi-wk kptm, .N� P brut _ I hereby agree to conform to all the Rules and Regulations the Town of rnsta r gar ' g the above construction. e ..... .d ... ....y. G ............ Barrows, Vita No ..21.521.... Permit for 1. 21 .. Adc .n..AQrch...ta.... ....................................................... . .... Location .......617.........West..........Nq17.n..�$.to..HyanYli•S•• ............................................................................... Owner ..... Vita Barrows............................... `4 P Type of Construction ....Wood............................. ..............•...................•........................................... 5..,^, .«• r _ �; • .'J. ' .Q..-. Plot ........................ ... Lot .. a. Permit Granted 19 JuYy '30- 79 « Date of Inspection Date Completed ...... ... ....: :......197 PERMIT REFUSED t } ..... $.........r''�.......................... .. 19 ....... •. �.....................................may• ............. } _ ^ i.• " � �.•'. �, ., r ......•............... ....... r i '1 •.i1^ 1 N . ........................:................... , M t ............................................................... . ............................................................................... s. ' S �oF1HE Town of Barnstable *Permit#### O Expires 6 months from issue date Regulatory Services Fee . sARNSTABLE, 9qjMASS. 16 ��� Thomas F. Geiler,Director ATfp�,tA , Building Division p IO�L3lo� PRESS PERMI om Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038,,nn��nn ��qqgg�� Fax: 508-790-6230 TO\NN OEII'WA`��RMIT APPLICATION - RESIDENTIAL ONLY V e l / Not Valid without Red X-Press Imprint Map/parcel Number 0 o!9 A f Property Address 4;[ /n CfJs 9Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address r d1�D Z, Contractor's Name s,, ,, �� 6; � �ga Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 01—I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value 0 0 (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors Licenseis r quired. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 090809 t The Cornmonfvealth of Massachusetts Department of Industrial Accidents !T, _•' Office of Investigations f3 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name (Business/Organization/Individual): X L Address: p City/State/Zip: Phone 2 S Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. El Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12 ❑Roof repairs insurance required.] # c. 152, §1(4),and we have no employees. [No workers' 13�'Other /,(L�,,, UzS comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic:#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify it er the pains andpenalties ofperjury that the'informationprovided above is true and correct. Si ature:- n Date: ®— Phone#: o — Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: r Information and Instructions I Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should-you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a.reference number. In addition,an applicant that must submit multiple permit/license applications in any given year; need only.submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 • www.mass.gov/dia II - THE row Town of Barnstable Regulatory Services 9snxxneiE$ Thomas F. GeUer,Director. 16i p;- Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstabie.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must °. Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relativ6 to`work authorized by this building permit application for. ��l L (Address of Job) `p Signature of Owner- Date zYArZka ktV � w Pnnt Name If Property Owner is applying-for permit please complete the Homeowners License Exemption Form on the reverse side. . Q:FORMS:OWNERPERMISSION Town of Barnstable :f o Regulatory Services -� r3wxtvsr.�sr.s, Thomas F.Geiler, erector • Mersa 9q, 1639. Building Division pTFD MAt a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 0_9 A r JOB LOCATION: 47 number eat village "HOMEOWNER": name ho phone# work phone# CURRENT MAILING ADDRESS: QQ r 8L � city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other ' applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requir nts. Gd.GL�D + Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results.in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\bomeexempt-DOC Town of Barnstable *Permit� �(1'(((�(���(;, Expires 6 m Jr onthsom issue date Regulatory Services Pr Thomas F. Geiler,Director Fee �— Blil«jng Divl$IoII Tom Perry, y,CBO, Building Commissioner SAMW ABLE 200 Main Street,Hyannis MA 02601 Office: w62-4038 w wN.town.barnstable.ma.us ��8-8 EXI'R SS PERMIT APPLICATION Fax: 508-790-6230 Not Valid H itltout Red X--Press RESIDENTIAL ONLY /parcel Number erty Address 17'- esidential Value of Work - 'a— �� � Minimum fee of$25.00 for work under$6000.00 er's Name&Address � r 2 actor's Name Telephone Number �2 e Improvement Contractor License#(if applicable) $or's-Lirrnse-#-(•rf-app hcab i e) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor Q I am the Homeowner ❑ I have Worker's Compensation Insurance ce Company Name an's Comp.Policy# f Insurance Compliance Certificate must be on file, Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) '"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic Conservation,etc. ***Note: Property O vrner must sign Property Owner Letter of Permission, copy of the Home Improvement Contractors License is required.q ed. iURE Z. pmtrg ;06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street . Boston,MA 02111 ,,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L,e 'lal Name(Business/Organizatiowlndividual): . i Address: ic City/State/Zip:�.it,,,Z *V_ 0 2 gal Phone.#: S o8) g'?4 Are you an employer? Check the appropriate box: Type of project(required):, 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-.time). have hired the sub-contractors 6. ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling shipand have no employees These sub-contractors have 8, ❑Demolition . working'for me in any capacity. employees and have workers' coin insurance.t , 9. ❑Building addition [No workers' comp,insurance R required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1�Roof repairs insurance required.]t c. 152,§1(4), and we have no 13,❑ Other employees. [No workers' comp,insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check.this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees: If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#:or Self-ins. Lic.#: Expiration Date: lob Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of - Investigations of the DIA for insurance coverage verification I do hereby certi der thZ_W�� ' sand penalties of perjury that the information provided above is true and correct. Si ature: _ Q S' Date: o 17 Phone#: S'vc9 92V2S514` Official use only. Do not write in this area,to be completed by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: o Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or.implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the -receiver or-tr stee of an individual partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for:the performance of public work until acceptable evidence of compliance with the insurance requirements.of this chapter have been presented*to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if . P P necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lin6. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in_(city town).":A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you ui advance for your cooperation and should you have any questions.J- please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston, MA 02111 TO.## 617-727-4900 ext 406 or 1-877 MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gavldia -f- oCJHE, Town of Barnstable. 4p� O Regulatory Services Bnxtvsra8�, � . suss. Thomas F.Geiler,Director 1619- Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma,us Office: 508-862-4038 Fax: 5 08-790-62 3 0 Property Owner Must Complete and Sign This Section If Using .A.Builder as Owner of the subject property herebyauthorize to act on my behalf, in all matters relative to work authorized bythis building permit application for: . (Address of Job) Signature of Owner Date Print Name Q:FORM S:OW r MRP ERMIS S ION t